Healthcare in China

Dr. Adam Powell and Dr. Youfa Wang, two of several presenters at this past weekend’s US-China Intercollegiate Healthcare Conference held on Wharton’s campus, exhibited a shared awe of the rapid changes taking place in China’s healthcare profile. Among the many themes and viewpoints presented at the conference, the sense of awe emerged as the common meeting point for all attendees.

“Just look at what China has been able to do,” Dr. Powell gushed while pointing at a chart depicting the staggering rise of insurance coverage in China from 2000 to 2012. The rate of China insurance coverage has reached 95%, according to the latest numbers put forth in this months March 2nd issue of medical journal the Lancet [link no longer exits]. “In ten years [Chinese health planners] have managed to cover a billion people.”

“Every time I visit China, I’m very surprised by the many changes,” Dr. Wang, a Johns Hopkins Medical School Professor and probably the leading expert on nutrition in China, said as he pointed at his own PowerPoint slide earlier in the day, a map depicting all of China’s KFC restaurant locations. The image made the audience of ninety students and health professionals chuckle and wiggle uncomfortably in their seats.

Yet for all the agreement on the pace of change in China, Dr. Shujun Li, the recently retired head of Beijing United Family Hospital’s surgery unit was still greeted with a roomful of approving nods when he pointed out that “the term ‘market’ does not fit to today’s situation” in the sphere of Chinese hospitals and clinics. Similarly, there was a rustling of pencil on paper and a clattering of laptop keys when keystone speaker Sheldon Dorenfest, CEO of the Dorenfest China Healthcare Group, said that in China’s broader healthcare sphere the market is not the private market. Rather, “the market is the public market.”

For some, one or both statements may seem confusing. Beijing United is one of China’s two largest, private for-profit hospital chains and it is foreign owned. Yet here we have one of its medical officers saying that despite all of this, a healthcare market in China is an illusion. The Health Statistics Yearbook 2011,put out by the Chinese Ministry of Health shows that there were 13,850 public hospitals in China in 2010, compared to 7,068 non-public hospitals, hardly numbers suggesting a non-existent private market.

Two key insights make sense of Dr. Li’s statement.

First, for the majority of Chinese, healthcare is only accessible with the aid of public insurance, so there is no private market to which they can turn for alternative, non-profit services. Moreover, the health institutions they can reasonably access are all regulated by the same price control mechanisms so almost all fees will be identical. Because they cannot choose between healthcare providers on the basis of any meaningful entities, they are not really a market consumer and for them there is no market. There is a strong argument to be made that a market exists when underground practices like red envelope payments are considered but that’s an article for another day.

Second, for those Chinese who can afford to look towards private healthcare providers they don’t really have 7,068 non-public hospitals and clinics from which to choose. The majority of these non-public healthcare “hospitals” are mom and pop healthcare businesses, like elective procedure providers and check-up centers, and dental offices, that offer little or no clinical services. For example, Beijing United is successful because no other non-public hospital in Beijing offers what it does: a full range of clinical and preventative services. So, even in the realm of non-public, i.e. ‘private’ hospitals and clinics, consumers really have no choice and therefore, in a sense, there is no market.

And the insights that explain Dr. Li’s statements are critical for understanding Mr. Dorenfest’s point on the existence of a public market only. The dominance of public entities in the healthcare market who admit patients, dispense drugs and purchase medical equipment, and the small size of the private healthcare market – and, again, the private healthcare market gets very small if you don’t count the mom and pop enterprises with little or no buying power – means that entrepreneurs have to work with public entities or risk failure by betting on a very short list of private market clients.

As a side note, I am not seriously positing that there is an absence of a healthcare market in China, per se. “The public market is the market,” to be sure, is not equivalent to “there is no market.” There are many things that can be done to operate profitably in a public market, and a public market is a form of market. A combination of pharma sales and hong bao are presently being used to circumvent price controls. Also, even though pricing may be fixed, hospitals may compete with each other to some extent for volume or case-mix (some procedures may be more desirable to perform than others). Further expounding on this point, if Beijing United is really the only hospital in its class as it claims, that does not mean there is no private market in Beijing – it means that Beijing United has a monopoly (a market with one dominant player). Beijing United likely monopolizes a small high-end niche market. Other Beijingers must make the choice between going to a myriad of specialty hospitals, TCM hospitals, village and county clinics, etc. Demand at these various places is determined by the choices of the Beijingers – a market exists.

Getting back to the point, however, the big lesson, which brings together both the points on dynamic change and public market dominance, is that investment in China’s healthcare market is a task which should not be taken lightly. Not only does the gravity of issues implicate — as conference presenter Michael Zakkour principal of Technomic Asia put it — “the future of China.” The complexity of the situation also demands of potential entrepreneurs in the area a sophisticated plan of action and not a ‘shortcut’ strategy which looks to cut out the complicated labyrinth of public institutions and ministries controlling the healthcare space. Mr. Dorenfest summed it all up with the last few words in his closing address, “Even though I was a very seasoned entrepreneur in the West, I was in preschool in doing business in China and had to learn more to be successful…[I]f I bought hospitals in China with what I knew about doing business in China I would be making bad investments be pouring money down the drain.”

Just read an interesting, disquieting, yet not terribly surprising article on China’s life expectancy. The article is entitled, “In China, Uneven Progress on Health Front,” and its focus is on how since 1990, China has had less of an increase in life expectancy than just about “every other big developing country” and even less than Bangladesh, Pakistan, South Korea and Sudan:

From 1990 to 2008, life expectancy in China rose 5.1 years, to 73.1, according to a World Bank compilation of United Nations data. Nearly every other big developing country, be it Brazil, Egypt, Ethiopia, India, Indonesia or Iran, had a bigger increase over that span, despite much slower economic growth. Since 2000, most of Western Europe, Australia and Israel, all of which started with higher life expectancy, have also outpaced China.

Though China has grown wealthier over the last thirty years, it has not grown healthier;

China can sometimes look like the economy of the future, having grown stunningly fast for almost 30 years now, lifting hundreds of millions of people out of poverty. But it, too, has real problems. Above all, its growth has been uneven. The coast has benefited much more than the interior. Almost everywhere, some aspects of life have improved much more than others.

Whether China can switch to a more balanced form of growth, as its leaders have vowed, will obviously have a big effect on the rest of the global economy. Yet it’s worth remembering that the biggest impact will be on the one-sixth of the world’s population who live in China. And arguably the best example is the fact that the country has grown vastly wealthier but only modestly healthier.

Though “many more people in China today “have acquired indoor plumbing, heating, air-conditioning or other basics. Other aspects of the boom, however, have pushed in the opposite direction”:

As in the Industrial Revolution, many people have left the countryside and poured into crowded cities. Accidents have become common, like the Shanghai fire last week or a series of workplace tragedies in recent months. Obesity is rising. Pollution is terrible.

I recently spent some time in China, and despite everything I’d heard in advance about the pollution, I was still taken aback. The tops of skyscrapers in Beijing can be hard to see from the street. Breathing the smog can feel like having a permanent low-grade sinus infection. For the Chinese, cancer has displaced strokes as the leading cause of death, partly because of pollution, notes Yang Lu of the Keck School of Medicine at the University of Southern California.

Every month or so I speak with someone who lived in China for many years and loved it, but left when their kid was born because they worried about the impact pollution would have on their kid’s health. I also not infrequently speak with clients whose top people in China are insisting they be transferred back to the United States or to Europe because they are suffering health problems from the pollution.

According to the United Nations, life expectancy in China is behind that of Sri Lanka, Tunisia, and Uruguay, among others, and it is currently five years behind that of the United States. Will China ever catch up with the United States on this? What do you think?

UPDATE: The China Bio Law Blog (which I just discovered) does its own riff on the statistics and, in an article entitled, “China Life Expectancy: The New York Times Visualized,” [link no longer exists] confirms China has not done well at all in terms of increasing the life expectancy of its citizens.

A couple years ago, I was on a panel at Northwestern’s Kellogg School of Business that was asked what we saw as the best opportunities for foreign businesses involved with China. We all agreed on the following five, in no particular order:

Healthcare

Education

Cleantech/Greentech

Food

Software/High Tech

Nothing shocking or earth shattering, obviously, but as time has gone on I have become even more convinced these are the top five. Last month I gave out this same top five list while interviewed on public radio and my interviewer expressed a bit of surprise at education.

Whereas three years ago, the above five “industries” clearly made up less than fifty percent of my law firm’s China-related work, I now estimate that these five now make up well over 75 percent and it is in those five where I continue to see the most growth.

If China’s health care spending simply keeps pace with projected GDP growth, it will increase to $480 billion by 2018. We, however, believe that it is likely to rise faster than GDP, as a result of better insurance coverage, improved access to high-quality care, and rising demand (tied to aging, urbanization, and lifestyle shifts). If health care spending hits 6.5 percent of GDP by 2018, the market could increase by an additional $150 billion.

McKinsey goes on to note that “private insurance could become cheaper and more accessible” in China, creating a $90 billion market by 2020 and that “regulatory reforms are making it easier for private hospitals to provide publicly-funded care.” McKinsey sees better health care requiring better IT as well. China is “set to overtake Germany to become the world’s third-biggest pharmaceutical market – with growth of 25-27 per cent next year, compared to an emerging market average of 15-17 per cent.”

The New York Times did a story today on the booming foreign education business for Chinese students, entitled, the China Boom. The story talks of how the number of Chinese undergraduate students coming to the United States to study has tripled in just the past few years. This increase in Chinese students attending college in the United States has led to a concomitant increase in the need for schools and tutoring both in China and in the United States to help these students prepare for their United States college experience.

I have always seen education and health care as being somewhat similar as they both become very important to people once they get past day-to-day survival mode. And as millions and millions of new Chinese hit the ranks of the middle class, I continue to see both growing faster than China’s GDP as a whole and I continue to see a whole host of opportunities for foreign companies.

What do you think?

Search…

About China Law Blog

We will be discussing the practical aspects of Chinese law and how it impacts business there. We will be telling you what works and what does not and what you as a businessperson can do to use the law to your advantage. Our aim is to assist businesses already in China or planning to go into China, not to break new ground in legal theory or policy.